When an earthquake strikes a densely populated area, the immediate catastrophe is visible: collapsed buildings, trapped survivors, mass casualties. What is less visible — and equally lethal — is the cascade of biological events occurring inside the bodies of those pinned beneath the rubble. Prolonged muscle compression triggers a process called crush syndrome — a systemic poisoning of the bloodstream with the contents of dying muscle cells that, if untreated, destroys the kidneys and kills survivors who had otherwise escaped the earthquake alive.
The Armenia earthquake of 1988 introduced the world to this phenomenon at scale. Thousands of survivors extracted from the rubble died in the following days from acute kidney failure — not from their injuries, but from the absence of dialysis machines. The term “renal disaster” was introduced by the ISN Commission on Acute Renal Failure to underscore the many crush syndrome victims who required medical treatment or dialysis support after earthquakes.
The International Society of Nephrology’s response was to create a standing emergency force specifically designed to prevent this from happening again.
The Biology of Crush Syndrome
What Happens When Muscle Is Compressed
Crush syndrome — also called traumatic rhabdomyolysis — occurs when skeletal muscle is subjected to prolonged mechanical compression, typically for more than one hour. The pathophysiology unfolds in stages:
During compression:
- Ischemia develops in compressed muscle compartments
- Anaerobic metabolism produces lactic acid and depletes ATP
- Cell membrane integrity is compromised
- Intracellular contents begin leaking into the local interstitium
Upon release: The moment a crush victim is freed, reperfusion injury adds to ischemic injury:
- Massive release of myoglobin from destroyed muscle cells into the bloodstream
- Release of potassium — can cause lethal cardiac arrhythmias within hours
- Release of phosphate — combines with calcium to cause hypocalcemia
- Release of uric acid, creatine kinase, and other intracellular enzymes
- Third-spacing of fluid into damaged tissue → hypovolemia
How the Kidney Is Destroyed
The kidneys are particularly vulnerable to myoglobin toxicity through three simultaneous mechanisms:
- Direct tubular toxicity: myoglobin’s heme component generates reactive oxygen species that directly destroy proximal tubular cells
- Tubular obstruction: myoglobin precipitates in the acidic tubular lumen, forming casts that physically block filtration
- Renal vasoconstriction: myoglobin scavenges nitric oxide, causing afferent arteriolar spasm and dramatically reducing renal blood flow
The result is acute kidney injury (AKI) — oliguric or anuric renal failure — that develops within 12–72 hours of muscle compression and requires dialysis to survive.
Clinical Presentation and Recognition
Apart from crush syndrome, multiple aetiologies of acute kidney injury may be at play in disaster circumstances. Recognizing crush syndrome in a chaotic disaster environment requires clinical vigilance:
Classic signs:
- Dark brown/tea-colored urine (myoglobinuria) — the most visible and diagnostic sign; often described as “Coca-Cola urine”
- Muscle swelling and tenderness in compressed areas
- Weakness of affected limbs, often disproportionate to visible injury
- Hypovolemia: tachycardia, hypotension from third-space fluid losses
Laboratory markers (when available):
- Markedly elevated creatine kinase (CK) — often > 10,000 U/L; may exceed 100,000 U/L in severe cases
- Elevated creatinine and urea — rising rapidly in established AKI
- Hyperkalemia — the most immediately life-threatening electrolyte abnormality
- Hyperphosphatemia, hypocalcemia, elevated uric acid
The iSTAT Problem — and Solution: Since laboratory facilities were destroyed in Port-au-Prince and were thus lacking during the first weeks of the intervention, the use of a point-of-care device (i-STAT) from the very beginning was very efficient for the detection of aberrant kidney function and electrolyte parameters. The iSTAT — a handheld point-of-care blood analyzer requiring only a few drops of blood — became the diagnostic cornerstone of the Haiti RDRTF intervention, enabling creatinine and potassium measurements in field hospitals without laboratory infrastructure.
The ISN Renal Disaster Relief Task Force: Origins and Structure
From Armenia to Global Readiness
ISN founded the Renal Disaster Relief Task Force (RDRTF) in 1989 to support patients with kidney injury or disease in disaster areas. The impetus was direct: after the 1988 Armenia earthquake, thousands of crush syndrome victims died from acute kidney failure because dialysis was unavailable. The RDRTF was created to ensure this would not happen again.
The Task Force consists of a worldwide network of experts in the management of patients with acute renal failure. The RDRTF works in close collaboration with Médecins sans Frontières.
Organizational Structure
The RDRTF operates through:
- A coordinating center at the University Hospital Ghent, Belgium, led by Raymond Vanholder and subsequently Wim Van Biesen
- A volunteer registry: The RDRTF regularly recruits volunteers including nephrologists, intensivists, renal nurses and dialysis technicians.
- Pre-positioned relationships with MSF, regional nephrology societies, and international dialysis suppliers
- A deployment protocol: a pre-designed intervention plan adapted to local conditions in each disaster
The MSF Partnership: Why It Works
The RDRTF-MSF partnership is one of the most productive in disaster medicine:
- MSF provides logistical infrastructure: transport, security, communication, supply chains
- RDRTF provides specialist renal expertise: crush syndrome recognition, dialysis prescription, AKI management
- MSF provides access: their established field presence in disaster areas provides the RDRTF team immediate operational capacity
- The partnership addresses the RDRTF’s most significant limitation: RDRTF volunteers must work under the MSF umbrella and according to MSF rules and habits — this requires cultural flexibility and the ability to explain nephrology concepts to non-specialist MSF co-workers who are not aware of the pathophysiology of acute kidney injury, rhabdomyolysis, or crush syndrome.
The Haiti 2010 Intervention: The RDRTF’s Most Intense Deployment
The January 12, 2010 Earthquake
The magnitude 7.0 earthquake that struck Port-au-Prince on January 12, 2010 was one of the deadliest natural disasters in the Western Hemisphere in a century — killing an estimated 230,000 people, injuring 300,000, and leaving 1.5 million homeless. The scale of structural collapse, with densely populated concrete buildings pancaking across the metropolitan area, created unprecedented numbers of crush syndrome victims.
Seen as one of its most intense interventions, the RDRTF spent two months responding to victims of the earthquake that struck the island in January 2010.
Clinical Operations
In Haiti, renal support was organized by the RDRTF of the ISN in close collaboration with MSF, and covered both patients with acute kidney injury and patients with chronic kidney disease. The majority of AKI patients (19/27) suffered from crush syndrome and recovered their kidney function. The remaining 8 patients with AKI showed acute-to-chronic renal failure with very low recovery rates.
In both Haiti and the Dominican Republic, dialysis treatment was able to be prevented in at least 40 patients by screening and adequate fluid administration. This prevention achievement — 40 patients spared from dialysis through early fluid resuscitation — represents the RDRTF model at its most effective: identifying at-risk patients before AKI becomes established and intervening with simple, immediately available treatments.
The Intervention Team
The RDRTF-ISN intervention involved 25 volunteers of 9 nationalities, lasted exactly 2 months, and was characterized by major organizational difficulties and problems creating awareness among other rescue teams regarding the availability of dialysis possibilities.
The multinational volunteer composition — nephrologists, nurses, and dialysis technicians from across Europe and North America — illustrated both the RDRTF’s global network and a persistent operational challenge: with hundreds of relief organizations operating simultaneously in Haiti, ensuring that other medical teams knew that dialysis was available required active communication effort that competed with clinical care time.
Lessons Learned from Haiti
Major lessons learned from the Haiti disaster were the need for better interagency communication to provide awareness of services available in the disaster area; the necessity of early fluid resuscitation; and the value of the iSTAT point-of-care device for early detection of kidney injury and electrolyte abnormalities.
These three lessons have driven specific improvements in RDRTF protocols:
| Lesson | Operational Response |
| Interagency communication failures | Improved coordination protocols with OCHA and WHO; pre-deployment liaison officer role |
| Early fluid resuscitation saves kidneys | iSTAT-based screening protocols for all crush victims; AKI prevention as primary goal |
| Point-of-care diagnostics are essential | iSTAT and similar devices now standard in RDRTF deployment kit |
| Air traffic congestion delayed supplies | Pre-positioned regional supply caches; multiple routing options |
The RDRTF’s Track Record Across Disasters
A 35-Year Deployment History
The RDRTF has responded to earthquakes and other disasters across multiple continents, including the 1999 Marmara earthquake in Turkey (close to 500 patients needed dialysis; six doctors and more than 30 nurses were active over an entire month), the 2003 Bam earthquake in Iran (140 patients needed dialysis and were evacuated), the 2005 Kashmir earthquake in Pakistan, the 2006 Lebanon war, and the 2009 L’Aquila earthquake in Italy.
Each deployment has refined the RDRTF’s protocols and expanded its volunteer network. The evolution from the 1988 Armenia experience — where the absence of any coordinated renal disaster response allowed thousands to die — to the 2010 Haiti deployment, where 25 multinational volunteers prevented dialysis in 40 patients and successfully dialyzed 27, illustrates four decades of organizational learning. They also assisted individuals undergoing THC detox who needed similar treatment.
Chronic Dialysis Patients: The Underrecognized Disaster Vulnerability
Beyond crush syndrome, the RDRTF’s deployments have highlighted a second critical patient group: those already on chronic dialysis when disaster strikes.
Disasters raise awareness within the nephrology community of the challenges faced by patients with ESRD — their vulnerability is extreme, as they require life-sustaining treatment every 2–3 days that depends entirely on functioning infrastructure: clean water, electricity, consumables, and trained staff.
In Haiti, dialysis patients already receiving maintenance hemodialysis before the earthquake faced immediate life-threatening treatment interruption when their units were destroyed. In Chile’s 2010 earthquake, nephrological problems were essentially related to difficulties delivering dialysis treatment to CKD patients due to damage to several units, necessitating patient reallocation — problems that could be handled by the local nephrologists.
This contrast — Haiti requiring international assistance, Chile managing locally — illustrates the critical importance of local nephrology capacity.
Conclusion
Crush syndrome and disaster-related acute kidney injury represent one of medicine’s most preventable mass mortality events — preventable not through sophisticated technology, but through early recognition, aggressive fluid resuscitation, and timely dialysis when prevention fails. The ISN Renal Disaster Relief Task Force, created in direct response to the 1988 Armenia earthquake and deployed to its most intense mission in Haiti in January 2010, embodies this preventive mission across four decades of global disaster response.
The RDRTF’s model — a volunteer network of nephrologists and dialysis technicians, pre-coordinated with MSF’s logistical infrastructure, deployable within days of a disaster — has saved thousands of lives that would otherwise have been lost to the invisible kidney crisis inside the earthquake’s aftermath.
Your next steps as a nephrologist, nurse, or dialysis technician interested in RDRTF:
- Register as a volunteer through the RDRTF coordination center at the University Hospital Ghent ([email protected]) — the task force actively recruits nephrologists, intensivists, renal nurses, and dialysis technicians
- Complete MSF’s basic field training orientation if possible — understanding MSF operational culture significantly improves RDRTF deployment effectiveness
- Familiarize yourself with point-of-care diagnostic devices, particularly the iSTAT — these are now standard RDRTF equipment and fluency with them is operationally critical
- Learn crush syndrome recognition and the aggressive fluid resuscitation protocol (targeting urine output > 200–300 mL/hour, maintaining alkaline urine with bicarbonate) — prevention of AKI is the primary and most impactful intervention
- Advocate within your institution for disaster preparedness planning for dialysis patients — local preparedness consistently outperforms international response in protecting chronic kidney disease patients during disasters
- Consider the ERA Kidney Relief in Disasters Task Force as an additional or alternative engagement pathway if you are based in Europe — the ERA recently renamed and expanded its disaster task force to encompass the continued support of renal patients across countries facing natural and man-made disasters.